Physiological response to posture change

ABSTRACT

In an embodiment, an implantable medical device includes a controller circuit, a posture sensing circuit, and a physiological sensing circuit. The controller circuit senses a change in a physiological signal as a result of a change in posture, and generates a response as a function of that change. In another embodiment, the controller circuit identifies a heart failure condition as a function of the change in the physiological signal.

TECHNICAL FIELD

Various embodiments relate to the field of implantable medical devices,and in an embodiment, but not by way of limitation, to the detection byan implantable medical device of a physiological response to posturechanges.

BACKGROUND

A person's health status may be determined by analyzing physiologicalparameters such as heart rate, respiration pattern, and blood pressure,just to list a few. These physiological parameters may follow differentpatterns for a healthy individual versus a person who is suffering fromsome form of ill health. Some physiological parameters are affected bythe posture of the body. Additionally, the present inventors haverecognized that the response of these parameters to changes in posturemay be affected by the person's state of health. Consequently, thepresent inventors have recognized that medical and health careprofession would benefit from a system and method to detect, capture,and analyze the effect of posture change on such physiologicalparameters.

SUMMARY

In certain examples, an implantable medical device includes a controllercircuit, a posture sensing circuit, and a physiological sensing circuit.The controller circuit senses a change in a physiological signal as aresult of a change in posture, and can optionally respond to thatchange. In certain examples, the controller circuit identifies a heartfailure condition or status using the change in the physiologicalsignal.

This summary is intended to provide an overview of the subject matter ofthe present patent application. It is not intended to provide anexclusive or exhaustive explanation of the invention. The detaileddescription is included to provide further information about the subjectmatter of the present patent application.

BRIEF DESCRIPTION OF THE DRAWINGS

In the drawings, which are not necessarily drawn to scale, like numeralsdescribe similar components throughout the several views. The drawingsillustrate generally, by way of example, but not by way of limitation,various examples discussed in the present document.

FIG. 1 illustrates a block diagram of an example embodiment of animplantable medical device.

FIG. 2 illustrates an example embodiment of a process to determine aphysiological response to a change in posture.

FIG. 3 illustrates an example embodiment of an implanted medical devicecoupled to an adjunct device.

DETAILED DESCRIPTION

The following detailed description refers to the accompanying drawingswhich form a part hereof, and in which is shown by way of illustrationspecific embodiments in which the invention may be practiced. Theseembodiments, which are sometimes referred to as examples, are discussedin sufficient detail to enable those skilled in the art to practice theinvention, and such embodiments may be combined, or that otherembodiments may be utilized and that structural, logical and electricalchanges may be made without departing from the scope of the presentinvention. The following detailed description provides examples, and thescope of the present invention is defined by the appended claims andtheir equivalents.

It should be noted that references to “an”, “one”, or “various”embodiments in this disclosure are not necessarily to the sameembodiment, and such references contemplate more than one embodiment.

The system and method described herein provide a system and method todetect a physiological response to a posture change. In one or moreexamples, the physiological responses include one or more of a change inheart rate, a change in heart rate variability, a change in heartsounds, a change in respiration rate, and a change in blood pressure.The change in posture may include one or more of a change from a moreupright posture to a more recumbent posture, a change from a morerecumbent posture to a more upright posture, and a change within arecumbent posture (e.g., changing from a supine position to a rightlateral decubitus position). The upright posture may include a standingposture or sitting posture or both, and the recumbent posture mayinclude one or more of supine, prone, right lateral decubitus, and leftlateral decubitus postures.

FIG. 1 illustrates an example of an implantable medical device 100. Inthis example, the device 100 includes a controller circuit 110. Thedevice 100 further includes a posture sensing circuit 140. The posturesensing circuit 140 may include one or more of a tilt switch, a singleaxis accelerometer, and a multi-axis accelerometer. The device 100 caninclude one or more of a memory circuit 130, an energy delivery circuit112 to deliver energy to a heart, a drug delivery circuit 114, a neuralstimulation circuit 116, a physiological parameter sensing circuit 120,a telemetry circuit 150, a comparator circuit 155, and an activitysensing circuit 118—any or all of which can be coupled to the controllercircuit 110. The telemetry circuit 150 is generally capable of beingwirelessly coupled to an external device 160. The physiologicalparameter sensing circuit 120 can include one or more of severalsub-circuits, such as a heart rate sensing circuit 122, a heart soundsensing circuit 124, a heart rate variability sensing circuit 125, arespiration sensing circuit 126, or a blood pressure sensing circuit128. The energy delivery circuit 112 may include one or more of a pacingcircuit, a anti-tachyarrhythmia pacing (ATP) circuit, a cardiacresynchronization therapy (CRT) circuit, or a defibrillation orcardioversion circuit.

In an example, the device 100 is implanted into a patient. The posturesensing circuit 140 senses the patient's posture, and transmits aresulting posture signal to the controller circuit 110. For example,this posture signal may indicate that the patient is recumbent, seated,standing, prone, supine, and/or in a right or left lateral decubitusposition. Substantially concurrently, the physiological signal sensingcircuit 120 senses at least one other physiological signal-differentfrom posture, but which may be affected by posture. Examples of suchphysiological signals may include heart rate, heart sound, heart ratevariability, respiration, blood pressure, or the like. The physiologicalsensing circuit 120 transmits to the controller circuit 110 aphysiological signal indicative of the sensed physiological parameter.In response to the received posture and physiological signals, thecontroller circuit 110 determines whether there is a change in thephysiological signal in response to a change in the patient's posture.The controller circuit 110 can further generate a response as a functionof the posture and physiological signals, such as in response to achange in the physiological signal resulting from a change in thepatient's posture. Such a response can include transmitting a control,alert, or other signal to one or more of the energy delivery circuit112, the drug delivery circuit 114, the neural stimulation circuit 116,and the telemetry circuit 150. In certain examples, such a response canindicate whether a patient's heart failure condition is improving orgetting worse.

In certain examples, the physiological signal is a heart rate, and thecontroller 110 determines a change in heart rate caused by a change inposture. A normal patient's heart rate typically increases upon standingup. However, while a patient with heart failure will also experience anincrease in heart rate upon standing up, such increase is believed togenerally be less than the corresponding increase for the normalpatient. Thus, in certain examples, the controller 110 can compare theheart rate response to posture to a normal patient's response todetermine an indication of whether the patient has heart failure, orwhether the patient's heart failure is improving or worsening. The heartfailure patient's smaller increase in heart rate upon standing can beused in several different ways. For example, the device may use thisinformation to identify that a patient is experiencing heart failure, toidentify whether the heart failure is improving or worsening, or both.For example, if a heart failure patient's heart rate response to achange in posture, such as standing, trends towards a normal subject'sresponse, then the heart failure patient's condition can be deemed to beimproving. If the heart failure patient's heart rate response to theposture change trends away from a normal person's response (e.g., thepatient's trend is toward an even smaller increase in heart rate uponstanding), the heart failure patient's condition can be deemed to begetting worse. In certain examples, in response to the improving,worsening, or constancy of the patient's heart failure condition, thecontroller circuit 110 can transmit a signal to the energy deliverycircuit 112, drug delivery circuit 114, neural stimulation circuit 116,or telemetry circuit 150, such as to initiate or adjust a responsiveheart failure or other therapy or to deliver an alert to the patient ora caregiver.

In another example, the blood pressure sensing circuit 128 senses achange in a person's blood pressure resulting from a change in posture.Changes in a normal patient's blood pressure are typically quite smallwhen going from a more recumbent position to a more upright position dueto a compensatory baro-reflex response of the body to maintain bloodpressure homeostasis. However, a person suffering from heart failuretypically experiences a greater decrease in blood pressure than a normalperson. Information about the degree of change in blood pressure inresponse to a posture change (or a comparison of this response to theresponse of a normal patient) can be used by the controller circuit 110to determine whether heart failure is present, improving, or worsening.As discussed above, the controller circuit 110 can use this informationto identify heart failure or its improvement or worsening, and canoptionally transmit a responsive signal to one or more of the energydelivery circuit 112, the drug delivery circuit 114, or the neuralstimulation circuit 116, such as to initiate or adjust a responsivetherapy, or to the telemetry circuit 150, such as to deliver an alert tothe patient or a caregiver.

In another example, the heart sound sensing circuit 124 senses a changein one or more heart sounds caused by a change in the patient's posture.The sensed heart sounds may be the normal heart sounds S1 and S2 causedby the closure of the mitral and tricuspid valves, and the closure ofthe aortic and pulmonary valves respectively. The sensed heart soundsmay also include the abnormal heart sounds S3, S4, and mitralregurgitation. The S3 and S4 heart sounds both relate to ventriculardiastolic filling. A normal patient will typically experience anincrease in heart rate upon becoming more upright. This also typicallyresults in an increase in heart sound energy. However, a heart failurepatient will typically experience a smaller increase in heart rate uponchanging to a more upright posture. As a result, the heart failurepatient will typically experience a smaller increase in heart soundenergy than a normal person. This information (or a comparison of thisresponse to the response of a normal patient) can be used to determinewhether heart failure is present, improving, or worsening, or if therapyshould be initiated or adjusted in response to the change, or if aresponsive alert should be delivered to the patient or a caregiver.While this example indicates that heart sound energy will not increasein a heart failure patient as much as in a normal patient, other effectsrelating to heart sounds for other types of heart failure conditions orother diseases may manifest themselves.

In another example, the heart rate variability (HRV) sensing circuit 125senses a change in heart rate variability in response to a change inposture. A normal person's heart rate varies in response to severalfactors, including a change in posture. However, it is believed that aheart failure patient's heart rate variability will exhibit a smallerchange in response to a posture change than a normal person. Thisinformation (or a comparison of this response to the response of anormal patient) can be used to determine whether heart failure ispresent, improving, or worsening, or if therapy should be initiated oradjusted in response to the change, or if a responsive alert should bedelivered to the patient or a caregiver. In certain examples, frequencycomponents of HRV may be extracted such as a high frequency (HF)component of HRV and a low frequency (LF) component of HRV. An LF/HFratio can be used to assess sympathetic/parasympathetic balance of theautonomic nervous system. For a healthy individual, the LF/HF ratio maychange by as much as 20% when transitioning a supine to an uprightposture. However, it is believed that a heart failure patient will notexperience as much of a change in LF/HF ratio in response to such apostural transition since sympathetic levels are already elevated.Similarly, this information (or a comparison of this response to theresponse of a normal patient) can be used to determine whether heartfailure is present, improving, or worsening, or if therapy should beinitiated or adjusted in response to the change, or if a responsivealert should be delivered to the patient or a caregiver.

In another example, the respiration rate sensing circuit 126 senses achange in respiration rate in response to a change in posture. A normalperson will typically experience an increase in respiration rate uponbecoming more upright. By contrast, it is believed that a heart failurepatient will typically experience a decrease in respiration rate uponbecoming more upright. This results from thoracic fluid accumulation ina recumbent heart failure patient that can make breathing difficult whenrecumbent, resulting in a compensatory increase in respiration rate whenrecumbent. Upon becoming more upright, some thoracic fluid moves out ofor away from the lungs, thereby making it easier to breathe. Thisinformation (or a comparison of this response to the response of anormal patient) can be used to determine whether heart failure ispresent, improving, or worsening, or if therapy should be initiated oradjusted in response to the change, or if a responsive alert should bedelivered to the patient or a caregiver.

As discussed above, the controller circuit 110 may be coupled to one ormore of an energy delivery circuit 112, a drug delivery circuit 114, ora neural stimulation circuit 116. When coupled to the energy deliverycircuit 112, any pacing or cardiac resynchronization therapy deliveredto the patient may be based at least in part on the information receivedfrom the posture sensing circuit 140 and the physiological parametersensing circuit 120. The pacing or cardiac resynchronization therapy canbe adjusted many different ways, such as by changing the rate of thedelivered pulses, changing the amplitude of the delivered pulses,changing the pulsewidth of the delivered pulses, adjusting the locationin the patient's heart where the pacing pulses are delivered, adjustingAV-delay, inter-ventricular delay, intra-ventricular delay, or adjustinganti-tachyarrhythmia therapy.

In certain examples, the controller circuit 110 is coupled to a neuralstimulation circuit 116. The controller circuit 110 can cause the neuralstimulation circuit 116 to transmit one or more stimulation pulses tothe autonomic nervous system (ANS) in response to a postural change inone or more physiological signals, where such stimulation of the ANS isdifferent from issuing a stimulation pulse to capture cardiac tissue toevoke a resulting heart contraction. For example, if the heart ratevariability sensing circuit 125 senses a lesser change HRV when thepatient changes posture, then one or more responsive neurostimulationpulses delivered to one or more ANS locations to influence the autonomicbalance and obtain a more normal HRV response to posture.

In certain examples, the device 100 can include a drug delivery circuit114 coupled to or included in the controller circuit 110. Using thephysiological response to posture information discussed above, apharmaceutical or other substance may be titrated into the patient. Forexample, if over time the patient exhibits a smaller heart rate increaseupon becoming more upright, a diuretic or one or more pharmaceuticalsmay be delivered to patient that relieve pulmonary fluid congestion. Incertain examples, a cardiac resynchronization therapy may beadditionally initiated or adjusted by the energy delivery circuit 112,such as to attempt to increase or restore the heart rate increase uponbecoming upright.

In certain examples, the device 100 determines the extent of thepostural change in the physiological signal by computing one or moreratios. In other examples, the extent of the postural change may bedetermined by a difference or other mathematical relationship. Incertain examples, the computation of the ration or other mathematicalrelationship may use a comparator circuit 155 that is coupled to orincorporated in the controller circuit 110. For example, this caninclude calculating a ratio of a physiological signal in a first postureto the physiological signal in a second posture. This ratio can becomputed for a healthy person and stored in the memory circuit 130 orthe external device 160. The device 100 calculates a similar ratio forthe particular patient in which the device is implanted, such as byusing information received from the physiological sensing circuit 120and the posture sensing circuit 140. These ratios can then be comparedat a particular time or over a time period, such as to determine theparticular patient's health status, which may include information aboutimprovement or worsening of such health status, particularly withrespect to heart failure. In certain examples, the ratio is calculatedas:

100*(RPP1/RPP2−1)

In the above equation, RPP1 relates to a resting physiological parametervalue while in a first posture, and RPP2 relates to a restingphysiological parameter while in a second posture. The activity sensingcircuit 118 may be used to determine periods when the person is at rest.Examples of physiological parameters that can be used in the above ratioinclude, by way of example, but not by way of limitation, heart rate,heart rate variability, heart sound amplitude, respiration, bloodpressure, or other physiological parameter that is affected by posture.Additionally or alternatively to the above ratio, a difference or othermathematical relationship may also be used to compare the patientphysiological response to posture to a threshold value, where thethreshold value can be established, in certain examples, using a healthyperson's physiological response to posture.

FIG. 2 is a flowchart that illustrates an example of a process 200 todetermine, analyze, and respond to a postural change in a physiologicalparameter. At 210, a change in posture of a body is detected. At 220, achange in a physiological parameter in response to the change in postureis determined. At 230, a degree in the change of the physiologicalparameter is determined. This can be accomplished by comparison to athreshold value, a comparison to a trend of similar values, or the like.At 240, an identification of a heart failure status (e.g., presence,improvement, or worsening) can be identified. At 250, a therapy, alert,or other response may be generated based on the heart failure statusinformation or directly from the postural change in the physiologicalparameter.

In certain examples, the device 100 includes a telemetry circuit 150,such as for communicating with an external device 160. In certainexamples, the telemetry circuit 150 transmits data collected by theposture sensing circuit 140 and/or the physiological parameter sensingcircuit 120, either before or after signal processing. This data maythen be analyzed, such as by the external device 160 or by a health careprofessional to determine the patient's status. Additionally, in certainexamples in which the device 100 or the external device 160 determines(e.g., using the postural change in the physiological signal) that theheart failure is worsening (such as during a decompensation episode) aresulting alert may generated and delivered to the patient or acaregiver. As illustrative examples, the alert may include one or moreof an audible signal, a text message, or some other signal to drawattention to the patient's worsening condition. This may help avoidhospitalizations resulting from decompensation episodes.

FIG. 3 is a diagram illustrating an example of a medical device system300 which can be used in connection with transmitting data from animplanted device 100 to an external device 160. FIG. 3 illustrates abody 302 with a heart 305. System 300 includes an implantable medicaldevice 100, a lead system 308, an adjunct device or system 160, and awireless telemetry link 360. Posture data, physiological parameter data,and other data may be transferred from the device 100 to the externalsystem 160 via the telemetry link 360. The telemetered data loaded intothe external system 160 can then be used for analysis and interpretationeither immediately or at a later time.

In the foregoing detailed description, various features are groupedtogether in one or more embodiments or examples for the purpose ofstreamlining the disclosure. This method of disclosure is not to beinterpreted as reflecting an intention that the claimed embodiments ofthe invention require more features than are expressly recited in eachclaim. Rather, as the following claims reflect, inventive subject matterlies in less than all features of a single disclosed embodiment. Thusthe following claims are hereby incorporated into the detaileddescription of embodiments of the invention, with each claim standing onits own as a separate embodiment. It is understood that the abovedescription is intended to be illustrative, and not restrictive. It isintended to cover all alternatives, modifications and equivalents as maybe included within the scope of the invention as defined in the appendedclaims. Many other embodiments will be apparent to those of skill in theart upon reviewing the above description. The scope of the inventionshould, therefore, be determined with reference to the appended claims,along with the full scope of equivalents to which such claims areentitled. In the appended claims, the terms “including” and “in which”are used as the plain-English equivalents of the respective terms“comprising” and “wherein,” respectively. Moreover, the terms “first,”“second,” and “third,” etc., are used merely as labels, and are notintended to impose numerical requirements on their objects.

The abstract is provided to comply with 37 C.F.R. 1.72(b) to allow areader to quickly ascertain the nature and gist of the technicaldisclosure. The Abstract is submitted with the understanding that itwill not be used to interpret or limit the scope or meaning of theclaims.

1. A system comprising: an implantable medical device, the implantablemedical device comprising: a posture sensing circuit; a physiologicalsignal sensing circuit to sense a physiological signal, thephysiological signal sensing circuit including at least one of a heartrate sensing circuit, a heart rate variability sensing circuit, a heartsound sensing circuit, a respiration rate sensing circuit, and a bloodpressure sensing circuit; a controller circuit, operatively coupled tothe physiological signal sensing circuit and the posture sensingcircuit, the controller circuit configured to detect a change in thephysiological signal that occurs in association with a change inposture, the controller circuit further configured to generate aresponse as a function of the change in the physiological signal,wherein the change in the physiological signal includes at least one of:a sensed change in heart rate that is less than a normal subject'schange in heart rate; a sensed change in blood pressure that isdifferent from a normal subject's change in blood pressure; a sensedchange in heart sound energy that is different from a normal subject'schange in heart sound energy; a sensed change in heart rate variabilitythat is different from a normal subject's change in heart ratevariability; and a sensed change in respiration rate when the change inposture includes one or more changes among a supine posture, a proneposture, a right lateral decubitus posture, and a left lateral decubitusposture.
 2. The system of claim 1, further comprising a telemetrycircuit operatively coupled to the controller circuit, wherein theresponse generated by the controller circuit comprises an alert issuedby the telemetry circuit to an external device.
 3. The system of claim1, comprising a pacing circuit coupled to the controller circuit,wherein the response generated by the controller circuit is to adjustpacing delivered by the pacing circuit.
 4. The system of claim 3,wherein the response generated by the controller circuit is to adjust apacing location of the pacing delivered by the pacing circuit.
 5. Thesystem of claim 3, wherein the response generated by the controllercircuit is to adjust a cardiac resynchronization therapy timing betweenpaces delivered by the pacing circuit.
 6. The system of claim 1, furthercomprising a neural stimulation circuit operatively coupled to thecontroller circuit, wherein the response generated by the controllercircuit is to adjust a neural stimulation pulse.
 7. The system of claim1, further comprising a drug delivery control circuit operativelycoupled to the controller circuit, wherein the response generated by thecontroller circuit is to adjust delivery of a substance.
 8. The systemof claim 1, in which the physiological sensing circuit is a heart ratesensing circuit.
 9. The system of claim 8, in which the heart ratesensing circuit senses a change in heart rate that is different from anormal subject's change in heart rate.
 10. The system of claim 1, inwhich the physiological sensing circuit is a heart sound sensingcircuit.
 11. The system of claim 10, in which the heart sound sensingcircuit senses a change in heart sound energy that is different from anormal subject's change in heart sound energy.
 12. The system of claim1, in which the physiological sensing circuit is a respiration sensingcircuit.
 13. The system of claim 12, in which the respiration sensingcircuit senses a change in respiration rate when the change in postureincludes one or more changes among a supine posture, a prone posture, aright lateral decubitus posture, and a left lateral decubitus posture.14. The system of claim 1, in which the physiological sensing circuit isa blood pressure sensing circuit.
 15. The system of claim 14, in whichthe blood pressure sensing circuit senses a change in blood pressurethat is different from a normal subject's change in blood pressure. 16.The system of claim 1, in which the physiological sensing circuit is aheart rate variability sensing circuit.
 17. The system of claim 16, inwhich the heart rate variability sensing circuit senses a change inheart rate variability that is different from a normal subject's changein heart rate variability.
 18. The system of claim 1, further comprisinga circuit to compare the change in the physiological signal, thecomparison comprising (1) a ratio of the physiological signal in a firstposture to the physiological signal in a second posture for a subjectwith a possible health condition, to (2) a ratio of the physiologicalsignal in a first posture to the physiological signal in a secondposture for a normal subject or population.
 19. The system of claim 18,wherein the ratio comprises:100*(RPP1/RPP2−1); wherein RPP1 relates to a resting physiologicalparameter while in a first posture; and wherein RPP2 relates to aresting physiological parameter while in a second posture.
 20. A methodcomprising: using an implantable medical device to determine a change ina posture of a body; determining a change in a physiological parameterin response to the change in posture, the physiological parameterincluding one or more of a heart rate, a heart rate variability, a heartsound, a respiration rate, and a blood pressure; and generating aresponse as a function of the change in the physiological parameter;wherein the change in the physiological parameter comprises at least oneof: a sensed change in heart rate that is less than a normal subject'schange in heart rate; a sensed change in blood pressure that is morethan a normal subject's change in blood pressure; a sensed change inheart sound energy that is less than a normal subject's change in heartsound energy; a sensed change in heart rate variability that is lessthan a normal subject's change in heart rate variability; and a senseddecrease in respiration rate.
 21. The method of claim 20, furthercomprising a circuit to compare the change in the physiological signal,the comparison comprising (1) a ratio of the physiological parameter ina first posture to the physiological parameter in a second posture for asubject with a possible health condition, to (2) a ratio of thephysiological parameter in a first posture to the physiologicalparameter in a second posture for a normal subject or population. 22.The method of claim 21, wherein the ratio comprises:100*(RPP1/RPP2−1); wherein RPP1 relates to a resting physiologicalparameter while in a first posture; and wherein RPP2 relates to aresting physiological parameter while in a second posture.
 23. Themethod of claim 20, further comprising identifying one or more of aprogression and regression of a health condition as a function of thechange in the physiological parameter.
 24. A system comprising: animplantable medical device, the implantable medical device comprising: aposture sensing circuit; a physiological signal sensing circuit to sensea physiological signal, the physiological signal sensing circuitincluding at least one of a heart rate sensing circuit, a heart ratevariability sensing circuit, a heart sound sensing circuit, arespiration rate sensing circuit, and a blood pressure sensing circuit;a controller circuit, operatively coupled to the physiological signalsensing circuit and the posture sensing circuit, the controller circuitconfigured to detect a change in the physiological signal that occurs inassociation with a change in posture, the controller circuit furtherconfigured to identify a health condition as a function of the change inthe physiological signal, wherein the heart failure condition isidentified by at least one of: a sensed change in heart rate that isless than a normal subject's change in heart rate; a sensed change inblood pressure that is different from a normal subject's change in bloodpressure; a sensed change in heart sound energy that is different from anormal subject's change in heart sound energy; a sensed change in heartrate variability that is different from a normal subject's change inheart rate variability; and a sensed change in respiration rate when thechange in posture includes one or more changes among a supine posture, aprone posture, a right lateral decubitus posture, and a left lateraldecubitus posture.
 25. The system of claim 24, further comprising acircuit to generate a response when the comparison indicates a change inthe health condition; and wherein the circuit to generate a responsecomprises one or more of a pacing circuit, a neural stimulation circuit,and a pharmaceutical delivery circuit.